DMAP Form .us
|[pic] |Substance Use Disorder Residential Treatment Admission/Discharge Notification Form |
|DIVISION OF MEDICAL ASSISTANCE PROGRAMS |Substance Use Disorder Residential Programs: Use this form to report when Oregon Health Plan clients enter or |
| |exit your program. |
| |Send the completed form via secure e-mail to DMAP Client Enrollment Services (CES) at ces.dmap@state.or.us. |
|CONFIDENTIALITY NOTICE: This document contains information which is confidential and/or legally privileged. The information is intended only for the use of the |
|individual or entity named above. If you are not the intended recipient, you are hereby notified that any disclosure, copying, distribution or taking of any |
|action in reliance on the contents of this information is strictly prohibited. If you have received this document in error, please immediately notify us via |
|secure e-mail at ces.dmap@state.or.us and destroy the documents received. Thank you. |
Client information
|1 Client Name | |2 Client ID | |
|3 Home Address | |
|4 City State ZIP | |5 Home County | |
|6 Does this client have accompanying dependent child(ren)? | Yes | No |
|If yes, enter the dependent child(ren)’s name(s): | |
Notification information
|1 Type of Notification (check one): |Adult admission |Adolescent admission |Discharge |
|2 Contact Person Name and Phone Number | |
|3 Name and Phone Number of person who completed this form (if different from Contact Person): |
| |
Program information
|1 Licensed Program Name: | |
|2 Treatment Program Name and Address: | |
|3 Treatment Program City State ZIP: | |
|4 Provider Billing ID | |5 Program capacity exceeds 16 beds? |Yes |No |
Admissions information – Report all admissions within 3 days of admission.
Do not bill DMAP or the CCO/MCO for newly admitted clients until DMAP CES confirms that they have processed your admission notification form. CES will notify you via secure email when this happens.
|1 Date of Admission | |2 First Date of Service | |
|3 Projected duration of stay (e.g., 90 days) | |
|4 Current physical health enrollment (check one): |CCO |MCO |FFS |
| If enrolled in a CCO/MCO, enter CCO/MCO name: | |
|5 Did you notify the CCO/MCO about this admission? |Yes |No |If no, please explain: |
| | |
|6 If program is outside the CCO/MCO’s service area, did you ask the CCO/MCO for an out-of-area referral? |
| |Yes | No |If no, please explain: | |
|7 How was the client referred to you? |Primary care |Court |Self | Outpatient program |
Discharge information
|1 Date of discharge | |2 Referred to outpatient program? |Yes |No |
|3 If yes, outpatient program name: | |
Substance Use Disorder Residential Program
Admission/Discharge Notification Instruction Sheet
Client information
|1 Client Name |Name of the person receiving treatment at your facility. Enter as listed on the client’s Oregon |
| |DHS Medical ID, Oregon Health ID or Plan ID. |
|2 Client ID |Enter the 8-digit identifier as listed on the client’s Oregon DHS Medical ID, Oregon Health ID or|
| |Plan ID. |
|3 Home Address |The client’s street address (where they lived prior to entering the treatment program).If the |
| |client is homeless, enter “Homeless.” |
|4 City State ZIP |The city, state and ZIP code of the client’s home address. |
|5 Home County |The county of the home address (not of the treatment program). |
|6 Does this client have accompanying dependents? |Check “Yes” or “No.” If the client has dependents residing with him/her at the treatment |
| |facility, also provide the dependents’ names. |
Notification information
|1 Type of Notification |Check “Adult admission,” “Adolescent admission” or “Discharge.” |
|2 Contact Person Name and Phone Number |This is the person we will contact if we have questions about information on this form. |
|3 Name and Phone Number of person who completed this form |If there is missing or invalid information on this form, we will contact this person first to ask|
| |them to resubmit the form. |
Program information
|1 Licensed Program Name |This is the name that appears on the actual license issued by AMH. |
|2 Treatment Program Name and Address |Enter the actual name of the program, if different from the licensed name. Also enter the |
| |physical address of the treatment facility. |
|3 Treatment Program City State ZIP |The city, state and ZIP code of the program’s physical address. |
|4 Provider Billing ID |Enter your 10-digit National Provider Identifier; or the 6- or 9-digit provider number issued by |
| |DMAP. |
|5 Program capacity exceeds 16 beds? |Programs that exceed 16 AMH-licensed beds are designated “Institutes for Mental Disease” (IMD). |
| |If you mark “Yes,” we will ensure that state (not federal) funds reimburse you for services. |
Admissions information
|1 Date of Admission |Enter the date the client was admitted to the facility for this report period. |
|2 First Date of Service |Enter the first billable date of service. |
|3 Projected duration of stay |Tell us how long the treatment plan will be (e.g., 90 days). |
|4 Current physical health enrollment |Tell us if the client is enrolled with a CCO or MCO, then enter the CCO/MCO name. If the client |
| |is enrolled with neither, select “FFS.” |
|5 Did you notify the CCO/MCO? |To coordinate care with the client’s CCO/MCO, you need to let the CCO/MCO know the client is at |
| |your facility. If you have not done this, please explain why. |
|6 Did you ask for an out-of-area referral? |If your program is outside the CCO/MCO’s service area, you need to coordinate with the CCO/MCO to|
| |make sure they will cover this service. If you did not ask for an out-of-area referral, please |
| |explain why. |
|7 How was the client referred to you? |Self-explanatory |
Discharge information
|1 Date of discharge |Enter the last day the client received treatment in your program. |
|2 Referred to outpatient program? |Enter Yes or No. |
|3 Outpatient program name |You must enter this information for all discharges. |
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